Dr Bruce Pollington web-ex presentation to LTC QIPP programme Utilising risk profiling, and risk stratification to identify patients with multiple long term conditions requiring complex care through integrated care teams.

1. Risk Profiling, LTC complex
patients, Integrated Care teams
& EoLC
Dr Bruce Pollington
Medical Director
The Heart of Kent Hospice March 2012

2. LTC QIPP Workstream
• Risk profiling to identify the top 5% (or 1%), ie
highest risk of admission to hospital in the
next 12 months.
• Developing Integrated Care Teams, multiprofessional, multi-agency providing holistic
care to the neighbourhood.
• Self Care programmes, giving back control to
people, imparting information and supporting
knowledge, ‘expert on ones self’.

3. Risk Profiling
• Risk profiling to identify the top 5% (or 1%), ie
highest risk of admission to hospital in the next
12 months, the top of the pyramid may be 20
times greater, then target selected populations
for integrated intervention 1,2,3,8
• By combining hospital, opd, A&E, and GP data
sets improves the PPV.
• Add in social care data
(1) Stuck, Siu, Whieland et al. “Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1992; 342: 1032-6
(2) Conn, Valentine & Cooper “Interventions to increase physical activity among aging adults: a meta-analysis”. Ann Behav Med 2002; 24(3): 190-200 S
(3) Fagerberg, et al. “Effect of acute stroke unit care integrated with care continuum versus conventional treatment. Stroke 2000; 31(11): 2578-84
(8) COMBINED PREDICTIVE MODEL FINAL REPORT Kings Fund 2006

4. Integrated working
• Developing Integrated Care Teams, multiprofessional, multi-agency providing holistic
care to the neighbourhood. 6, 11
(6) Integrated care for patients and populations: Improving outcomes by working together
Report to the Department of Health and NHS Future Forum from The King’s Fund and Nuffield Trust 2012
(11) Integrated team working: a literature review S. Maslin-Prothero International Journal of Integrated Care, 29 April 2010

5. SelfCare
• Self Care programmes, giving back control to
people, imparting information and supporting
knowledge, ‘expert on ones self’. 4
• Health and other outcomes5
–increase in life expectancy
–better control over symptoms
–reduction in pain, anxiety and depression levels
• Implications for the care system5
–visits to GPs can reduce by 40 to 69%
–hospital admissions can reduce by up to 50%
(4) RESEARCH EVIDENCE ON THE EFFECTIVENESS OF SELF CARE SUPPORT Department of Health 12 December 2007.
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_081251.pdf
(5)Self Care Support summary of work in progress (2005-07) THE EVIDENCE PACK DH July 2007
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_076932.pdf

6. The EoLC National Strategy
• Definition of EoLC
• By end of life care it is meant the services that
support those with advanced progressive
incurable illness to live as well as possible until
they die.
• These services enable the supportive and end
of life care needs of both patients and their
families to be identified and met throughout
the last phase of life and into bereavement

7. Holistic Care
• It includes the management of pain and other
symptoms and the provision of psychological
support. It is not restricted to any specialist
services and includes those services provided
as an integral part of the practice of any
health or social care professional in any
setting.

8. The 6 Steps in the EoLC Pathway
•
•
•
•
•
•
Starting the conversation
Assessment and care planning
Coordination of Care
Delivering high quality care
Last days of life
Care after death

9. The End Of Life Clinical Pathway
Coordination of Care for the patient
• Coordination of individual patient care
• Register-information shared across all sectors
Delivering high quality care
Starting the
conversation
•Open, honest
communication
• Identifying
triggers
for discussion
• Listening to cues
from patients
Assessment
and
care planning
• Assessment
and regular
review of
patients’ needs
• Care planning
• Assessing
carers needs
• High quality care
provision in all settings
Last days of life
• Rapid response services
• Identification of
the dying phase
• Hospital, community, care
homes, hospices, community
hospitals, prison, secure hospitals
and hostels
• Ambulance
Services
•All OOH services
• Spiritual care
Coordination of Care for carers
Care after death
• Review of needs
and preferences
for place of death
• Support for both
patient and carer
• Recognition of
wishes regarding
resuscitation and
organ donation
• Timely verification
and certification of
death
• Viewing of the
body/mortuary
facilities
• Return of property
• Care and support
of carer and
Family

10. End Of Life Care for all diseases
NEUROLOGICAL
CONDITIONS
COMPLEX FRAIL
ELDERLY
EOLC
DEMENTIA
LONG TERM
CONDITIONS
CANCER

11. Illustration of changing functional level
over last year or so of life.
Slide courtesy of Whole Systems Partnership

12. Some issues to consider
• It has been estimated that 42% may follow a frail
elderly functional decline trajectory, 9 Often this
group has no diagnostic pigeon hole and their
deterioration goes ‘largely’ unrecognised
• 73% of patients on GP Palliative Care QOF have a
diagnosis of cancer, but cancer represents at
most only 30% predictable death, 10
(9) Whole Systems Partnership, National EoLC Programme Et al Nov 2010
(10) NEoLCIN

13. Some issues to consider
• At any one time about 25% of inpatients in
acute hospitals are in their last year of life
• On average people are admitted to hospital
three times and spend nearly a month of the
last year of their life in hospital

14. Complex Patients
• Risk Profiling really is identifying the complex
patients. Or to put it another way, the people
that would benefit most from a holistic and
integrated approach to their care.
• A High proportion of this group will also be
the patients making the transition into End of
Life

15. Which Percentage Groups should
we be looking at?
• Due to considerations called regression to the
mean, LTC case management may need to
look just below the highest risk to have time
to make a difference
• But who is in the top 1% and is there still time
to make a difference?
• Many in the top 1% actually need something
different.

16. Risk profiling will help find the 1%
• 1% being the percentage of the population
who die each year. And a National Campaign
• As it stands, timely identification of the noncancer end of life care patients is presenting a
challenge.
• Risk profiling can help us leap frog over this
hurdle.

17. The top 1% need a change in focus
• For the top 1% integrated teams need to
seriously consider if their patient is entering
EoL or they will continue to have an average of
3 admissions in that last year.

18. The transition from LTC to EoLC
• Need to move away from the handing over
the baton model.
• This relay race model of service provision
leads to late referral and perpetuates the silo
culture.
• We need to integrate disease management
with symptom management

19. People Call Ambulances because of a
deterioration in their symptoms.
We give disease management advice
but as a collective we tend to
‘withhold’ symptom management until
we diagnosis a person as at end of life.
Traditionally Palliative Care services
would decline to see non-EoLC
patients as not meeting the criteria.

20. The COPD suffer is a good example
or indeed anyone suffering with
SOB, there is good EBM for the use
of morphine yet we withhold its
use, you have to be dying before
your symptom of SOB is treated.

21. So what should the model of care
look like.
• Integrated Care where the treatment and
support provided is based on assessed needs
with absolutely no arbitrary boundaries
• Also we need to front load assessment and
care so people can gain the maximum benefit,
hence retaining the maximum independence.
• An earlier OT home assessment being a good
example. It is rare to need repeating.

22. Front load
So what with
should the model of care
assessment
earlier
intervention
look like.
Dementia
Physical
OA
CKD
COPD
LVF
Psychological
Social
Spiritual
Disease management
Symptom Management
Integrated Care Team for complex high need people

23. How can technology help us?
•
Risk profiling to find the complex patients. Additional modelling may be developed
to identify the frailty group, who are at high risk of dying but perhaps not at high
risk of admission, this group may otherwise deteriorate relatively un-noticed.
•
Integrated Care Teams (NHS, social services, voluntary sector) to provide holistic
assessment, with both disease and symptom management aiming to support
independence. Use video-conferencing to link patients and families with the team
and experts as needed bringing them closer to the decision making
•
Self Care and escalation planning or personalised care plan. Deploy telehealth
devices to the high risk group, these can have first tier self-care escalation advice
tailored to the individual.
•
Link teleheath device to urgent care dash board, efficient monitoring to alert the
integrated team of changes to health status directing early intervention.
•
“The key is to integrate these technologies into the care and services that are
delivered. Going forward this evidence [WSD] gives us confidence that we can
transform the way services are delivered”7
(7) Whole System Demonstrator Programme Headline Findings – December 2011 DH

24. We can use Risk Profiling to predict the
future risk.
• How can you get ahead of the curve?
• We want to identify the patients with
increasing risk before they are the highest risk.

25. How to get ahead of the curve?
• For any individual the risk of admission is dynamic.
• The rate of change in risk will vary from one
individual to another.
Top 1%
Top 5%
Top 30%

26. • The white arrows represent what is happening
to the admission risk for individuals over a
given time.
• While for the majority the risk alters little over
any given time period, for some the risks are
escalating rapidly
Top 1%.
Top 5%
Top 40%
The risk is static for this individual

27. How to get ahead of the curve
Risk of hospital admission
1st
500th
At this point
the
individual
enters the
top 1%
5000th
On the way up there is plenty of scope
for a rapid increase while at the top of
the curve there is little head room left
for further increase in risk, hence the
rate of increase tails off
Time

28. Risk of hospital admission
Rate of change in risk of
hospital admission
By regularly (or preferably constantly) running the
risk tool we can plot individuals change in risk
over time, we get new graph, the rate of change
of risk.
Time

29. Risk of hospital admission
Rate of change in risk of
hospital admission
As you can see the peak in rate falls ahead of the
absolute maximum, roughly speaking a quarter
cycle ahead.
It buys this much time to
prevent the admission
Time

30. On a population basis we should profile for those with the
highest rate of increase in risk of hospital admission, they
are the most unstable patients.
Risk of hospital admission
Rate of change in risk of
hospital admission
Top 1%
It buys this much time to prevent
the admission
Time

31. Dr Bruce Pollington
Bruce.pollington@hokh.co.uk
01622 792200